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Prison Psychotherapy

The curious thing about my sessions with Balsam was that I kept imagining her wearing a backpack, sandwiched between herself and the plastic chair where she sat. I was working as a psychologist at a maximum-security prison, and I’d seen other inmates traveling the walkways with prison-issue clear plastic backpacks. But Balsam was in the therapeutic behavioral unit, for inmates with mental illness who had been placed in solitary confinement. Because they were rarely permitted to leave the unit, these inmates didn’t need backpacks.

The first few times I thought Balsam was wearing a backpack, I suspected the illusion was a product of how her upper body frequently dipped forward and down. Every so often, she’d square her shoulders and restack the vertebrae of her upper spine. By our fourth session, I began to wonder if the illusion might be less about my having a misapprehension and more about her carrying some kind of burden.

“You’re getting out of prison in less than a year, is that right?” I asked her that day, after we settled into the interview room. The room had large windows on three sides so that corrections officers could monitor her behavior.

“It’s just under six months now,” she said. “I’ll be out by my 26th birthday.”

“That’s terrific,” I said. “What are you thinking of doing when you go?”

“I’m going to work with animals,” she said. “My family lives outside of Albany. We board horses during the winter. I might study to be a vet.”

I could see that. There was something outdoorsy about Balsam, scrubbed and friendly and unassuming.

“You’re close to your family?” I asked. “That’s something that can make a big difference for women returning to the community.”

“Oh, you don’t have to worry about me, I’m never coming back,” she said, reaching for her straw-colored hair, which was gathered at her neck with an elastic tie. She inspected the ends. We sat in silence for a moment.

“But I wonder if there’s something … ” I began. She shifted her focus, looked at me blankly. I tried again: “Anything you worry about when you think of returning home?”
“Most of these girls have had it much worse than me,” she said, glancing toward the cells across from the interview room. “I’m really one of the lucky ones.” She looked down at her fingers, started to pick at a cuticle.

“I get that,” I said. “But we have this time every two weeks, it’s your time. Is there anything that you’ve had to shoulder, any kind of burden that you think might lead you to drugs again?” I mentioned drugs because she had told the other women in the group therapy sessions I was running that her crime was drug-related.

“Like you don’t know,” she said, frowning.

“Know what?” I asked.

“It’s got to be all over my chart,” she said.

“Oh,” I said. “Well, I don’t usually read about people ahead of time.”

I had long ago stopped looking into the charts of the women on the unit, except to add my own notes after each session. These women usually had charts the size of dictionaries, filled with legal narratives, histories told by various clinicians, psychological assessments, psychiatric evaluations, medical records, lists of drugs and diagnoses and treatment plans that were tried and discarded. I began to wonder how any of these women would ever escape so many sad renderings of their lives; I didn’t want to get snared by them myself.

“How come you don’t read about us?” Balsam asked, still absorbed by the margins of her thumbnail.

“I’d rather hear things from you, what’s on your mind, not what I think is important,” I said. “And, well, I’m a bit lazy.”

She smiled, glanced up at my eyes to see how to take that last part. I smiled a bit in return.

“Well, sorry, I thought … ” she said, and then started to straighten up again but changed her mind and let herself slouch, her back against the chair. She inhaled deeply.

“My mother killed herself when I was 14,” she began. “I found her in the laundry room of our farmhouse. That’s what everyone like you wants to talk about, like it’s the key to me.” She folded her arms across her chest, and thrust her legs out straight. “I don’t talk about it with the girls, with anyone anymore,” she went on. “I don’t see how anyone can understand what I’ve gone through. No offense, I know you’re a professional and all, but even you couldn’t really understand.”

Balsam’s revelation triggered a silence. Should I tell her that I could understand? That I had discovered my own mother’s suicide when I was a teenager? Would telling her my story drive home that she was not alone in the world? I imagined her backpack slipping off and her floating up to the ceiling, bopping along gently until she escaped through the skylight and drifted beyond the razor-wire fencing.

Harry Harlow, an American psychologist, conducted a series of famous experiments where infant monkeys were separated from their mothers. These babies were instead provided with various alternatives. In one experiment, one “mother” was made of wire but had a nipple that dispensed milk. Another was just wood covered in terry cloth. Most babies preferred the cloth mother that didn’t dispense anything rather than the wire monkey that dispensed actual sustenance. The babies raised with cloth monkeys ended up more sound, secure and adaptable.

Prison is all about providing wire monkeys. Inmates get clothes and food and shelter, maybe a G.E.D. But they don’t get the kind of warmth, comfort and understanding that can help them truly change, prepare them for a better life outside. If I were to tell Balsam about my mother’s suicide, would I be just another wire monkey, dispensing a superficial intimacy rather than providing true support?

I cleared my throat, looked Balsam in the eye. “So it’s a pretty big risk to tell me that,” I said, “even though you’re kind of sure, from your experience, that it won’t help you much. That you might feel even more alone as a result of telling me, because how could I ever understand, really understand, what you’ve been through.”

“That about sums it up, Dr. Gross,” she said. “Whenever I’ve told someone else, I feel like they get freaked out or feel sorry for me or they feel like they have to make it better. Either way I have to make things better for them, pretend I’m fine, whatever.”

“Maybe there’s a way we can talk about it,” I said, “so that you have a different experience. I wonder if you’d be interested in what that could be like?”

Working in prison is one of the few times when, as a therapist, you hope never to hear from your patients again. Balsam has now been out for more than three years without violating her parole, and having satisfied that requirement, she’s truly free. I like to think that the conversations we had after that session helped repair some of the trauma that led to her drug use and prison time. I opted not to tell her about my mother’s suicide. What I did share was my certainty that her understanding of her mother’s suicide could evolve as she moved further into adulthood, and my hope that she would leave incarceration less burdened than when she arrived.Steve Gross was the chief psychologist for corrections-based operations for Central New York Psychiatric Center, which provides mental health care in New York State prisons. He currently has a private practice in Manhattan.

Details have been altered to protect patient privacy.

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Couch features essays by psychotherapists, patients and others about the experience of therapy — psychoanalysis, cognitive behavioral therapy, group therapy, marriage therapy, hypnotherapy or any other kind of curative talk between people behind closed doors. To contact the editors of Couch, send an email to opinionator@nytimes.com. Please include “Couch” in the subject field.